CONCORD — In a union hall a mile from New Hampshire’s gold-domed statehouse, Joe Biden was working a rope line, taking selfies, clapping voters on the shoulder, when a woman with a red plaid dress and a message got her turn.
“Health care is so important,” Sheila Zakre told the former vice president running for the Democratic presidential nomination.
A 61-year-old disability rights lawyer who works on her own, Zakre is part of the insured middle class. Still, she and her husband, Bob Sanders, are fighting an unexpected $2,400 hospital bill after a facility fee was tacked on for a scan in a doctor’s office.
She is legally blind and holding off replacing her special glasses after they broke weeks ago because the $800 cost is not covered by the health benefits they get through his job. And though he turns 65 next month, he is thinking of working until she is old enough for Medicare, too, because, without his insurance, her premiums for an Affordable Care Act health plan would be nearly twice what they pay now.
“The Affordable Care Act is just not affordable for us,” she said.
This first-in-the-nation primary state is also at the leading edge of Americans’ frustration with flaws of the U.S. health-care system. In conversations as well as in standing-room-only audiences at town hall gatherings with the presidential candidates, the system’s flaws come up often: the expense of prescription drugs, a scarcity of mental health services, coverage gaps, care difficult to afford even for people with private insurance.
Some 28 percent of likely Democratic primary voters in New Hampshire consider health-care the most important issue in deciding whom to vote for, according to a November Quinnipiac poll — the highest-ranking issue here, as well as nationwide, according to another Quinnipiac poll. Nearly half of New Hampshire Democratic voters said in a WBUR/MassINC poll last month they want candidates to talk about health care — far surpassing any other topic.
With its tradition of presidential contenders meeting face-to-face with residents in relatively intimate settings, New Hampshire has a history of sensitizing candidates to the matters that are on its voters’ minds.
In 2008, a Service Employees International Union project printed purple T-shirts and stickers saying, “I’m a health care voter!” and made sure the purple was plentiful at New Hampshire primary events, recalled Concord City Council member Zandra Rice-Hawkins, the executive director of Granite State Progress, an advocacy organization for which health care is a flagship issue. The project contributed to President Barack Obama’s rapid focus on what grew into the ACA, Rice-Hawkins said.
And in 2016, when the opioid crisis had taken hold hard here, candidates heard from voters, in tears, about family members’ addictions and deaths.
Hillary Clinton attended a reception at the home of the New Hampshire state Senate president and recounted having just met with the head of a company who had told her that 40 percent of his workers regularly failed drug tests he required, recalled Ned Helms, a longtime Democratic activist and former state health commissioner who founded the University of New Hampshire’s Institute for Health Policy and Practice. “I think it was an awakening,” Helms said.
“In this cycle, I don’t think I’ve been at a town hall meeting ... where health care hasn’t come up on the part of the people,” said Helms, a Biden supporter who has attended events over the months by virtually every Democratic candidate. “People really want to know what you are going to do.”
Campaign gatherings here seem to be nudging the Democratic field beyond its running internal dispute over whether the country should shift to a single-payer health care system. Candidates are bringing up mental health needs and the pain of worrying about medical bills on top of diagnoses. Republicans “always want to cut people’s health care because it’s too expensive to let people live,” candidate Tom Steyer said Wednesday night at a crowded town hall in a Manchester pub.
Fueling voters’ concerns, the state has “some of the highest costs — out-of-pocket costs and premium costs — in the region, and they continue to go up,” said Lucy Hodder, a UNH health law professor and former senior health-care adviser to then-Gov. Maggie Hassan, now a U.S. senator.
New Hampshire has the nation’s third-highest proportion of residents with job-based insurance that features a high deductible — the amount consumers must pay up front before their coverage begins.
“My own employees were avoiding getting care,” said Joanne Conroy, president of Dartmouth-Hitchcock Health, New Hampshire’s largest private employer. Last year, Dartmouth-Hitchcock began chipping in most of the money to health-savings accounts for lower-income workers and increased its contribution for employees with incomes of up to $150,000.
Even so, the costs can be overwhelming. Kat Barrell, a Dartmouth-Hitchcock marketing manager, discovered in the fall of 2016 that the pressure she had been feeling in the lower right side of her abdomen was a four-pound ovarian tumor — clear cell carcinoma. After chemotherapy, her doctors said she was cancer-free, but it returned last summer, and she began an immunotherapy clinical trial.
The trial pays for the drugs, but not the CT scans she needs every six weeks at $9,000 each, or the infusion or doctors’ appointments. Even with a health plan that she thinks is fair, she faces a $2,800 deductible for herself and her teenage son. (The premiums would double if she included her husband, Chris, so he is on a health plan with a larger deductible through his job as a horse farm’s maintenance technician.) And at the start of each year, she dreads her plan’s $4,400 out-of-pocket maximum. Together, Barrell and her husband, who recently had knee surgery, have racked up about $37,000 so far for the expenses their insurance is not covering.
Her husband is postponing rotator cuff surgery, wanting to focus on paying for her care even though he works every day in pain.
Barrell, 49, said she doesn’t think of herself as a political person, but, this year, “health care is number one on my hit list.” She has known she could not support a candidate who favors a single-payer system, fearing it could rupture relationships with her doctors. She has just decided to vote for former South Bend, Indiana, Mayor Pete Buttigieg, who sprinkles his town-hall events here with talk of a Medicare-like option for consumers who prefer an alternative to private insurance.
Like an uncommon number of voters with the primary so close, Zakre, the Concord lawyer, expects to make up her mind Tuesday with a pencil in her hand in the voting booth. She likes that Medicare-for-all would cover long-term care, since many of her elderly clients cannot afford it. And she thinks it would end the difficult conversation she and her husband keep having: She saying she might spare the expense of insurance by going uncovered if he retired, and he insisting he then will keep working until she is old enough for Medicare, rather than leave her so vulnerable.
With one of the nation’s highest median ages and a fast-growing older population, the cost of prescription drugs is a major concern here. And people see close-up the limits of Medicare.
Michael Provost, 69, is part of a group of AARP volunteers, wearing crimson fleeces with white lettering, “Stop RX Greed,” that has fanned out to candidates’ events, documenting what they tell voters about their health care plans. “As a widower, we have been financially devastated by my wife’s illness,” he told Buttigieg on Tuesday afternoon in an art space in Portsmouth.
Provost figures that, before he lost his wife of 36 years, Sylvia, in 2016, her five years of illness cost them more than $200,000 in bills that her Medicare did not cover. “It was a horror show,” he said. After cancer, then kidney failure and a stroke, “at a time she was supposed to be healing, she was worried” that they had to cash in her retirement savings and then his.
Last Tuesday night, before Biden spoke and Zakre had her moment on the rope line, the candidate was introduced by Steve Shurtleff, speaker of the N.H. House of Representatives.
A year ago, Shurtleff, a Concord Democrat, formed a subcommittee to deal specifically with mental health. More and more often, he said, he hears of parents who can’t get a child into mental health treatment or drug rehab.
At a Biden town hall in Somersworth Wednesday, Dee Perrotta, another of the crimson-fleece AARP group, was near the end of that rope line. A recently retired psychiatric nurse, she told the candidate that people can’t always afford medicines to treat their disorders. At the community health center in Essex where she worked, she and psychiatrists pleaded with insurance companies to approve drugs that were new or simply not ones they cover.
At a town hall in Derry with Sen. Bernie Sanders, I-Vt., a college student holding a “Bernie” sign told him he has lined up a job as an insurance company analyst for when he graduates in May — and asked what would happen given that Medicare-for-all would wipe out private insurers. (“We will have a very just, unprecedented transition period,” Sanders replied.)
Underlying the candidates’ permutations — Medicare-for-all, Medicare for those who want it, a public option to improve the ACA — “it’s really universal health care people are aching for,” said Rice-Hawkins, of Granite State Progress.
With nearly 45,000 New Hampshire residents having signed up for ACA health plans this year, and about 57,000 now covered through the ACA’s expansion of Medicaid, “once you start to use it, you start to peel back the onion,” Rice-Hawkins said. “It can be tough, if you’re so excited to finally have health insurance, to realize there may be gaps.”
Helms, the longtime Democratic activist, said, “It’s emotional, and it’s financial. [Voters] get it in a very, very visceral way. And they want some assurance that the people asking for their vote have really thought about it.”
WASHINGTON — Americans increasingly rate this as the best economy since the late 1990s, with a recent surge in optimism, even though many economic metrics show striking similarities to the final years of the Obama administration.
Fifty-nine percent of Americans say they are better off financially today than they were a year ago, the highest since 1999, according to a Gallup survey released last week. And nearly three-quarters predict they will do better a year from now, the most optimistic reading that Gallup’s annual “Mood of the Nation” survey has ever recorded.
Other polls and surveys aren’t quite as ebullient, but nearly all show that Americans are far less worried about the economy and their personal financial situations than they were during the last presidential election.
Upbeat sentiment is critical for the U.S. economy because it motivates consumer spending, the most important driver of U.S. economic growth. And President Donald Trump is counting on a strong economy to motivate voters to turn out at the polls and re-elect him.
Bryan DeHenau runs a roofing business in Macomb County, Mich., just outside Detroit. Around the time of the last presidential election, he had enough jobs to keep one crew busy, but some of the gigs were barely profitable. Today he can keep three crews busy during the spring and summer months, and he has been able to raise prices, regularly giving people estimates of $20,000 to totally redo a roof and finding that “they don’t even bat an eye about it anymore.”
“I’m driving a brand-new 2019 Ford F-250. I’ve got work coming out the ying-yang. I’m doing OK,” DeHenau said. “Four years ago, I couldn’t sleep at night. That’s a pretty big turnaround.”
Some of the biggest recent increases in consumer confidence have come from independent voters and less affluent households, according to Richard Curtin, director of the University of Michigan Surveys of Consumers. His team always asks people to explain why they feel confident, and lately they are hearing near-record levels of people saying their income and wealth are rising.
“We’ve only seen this many people mention income gains twice before: 1966 after the 1960s expansion and 2000 after the 1990s expansion,” Curtin said.
In interviews with six small-business owners across the country, all acknowledged that the economy had turned around under President Barack Obama, but they pointed out that several more years of steady growth, solid job gains and additional stock market records under Trump had turned “cautious optimism” into full-blown optimism.
Business owners varied in how much credit they would give Trump personally, but all had examples of how they had more work than they could handle and were buying equipment and bringing on new people in ways that had not happened since before the Great Recession. Trump’s approval rating on the economy hit an all-time high last month, according to a Washington Post-ABC News poll.
On Friday, the Labor Department reported that the U.S. economy added 225,000 jobs in January, beating forecasters’ expectations and further dampening concerns about a recession. Many workers have also felt better off financially thanks to tax cuts, cheaper gas prices and minimum-wage increases in more than 20 states. Wage growth has inched up for rank-and-file workers in recent months, although it remains below the stellar levels of the late 1990s.
Economists say one of the biggest drivers of consumer confidence is job quantity. Confidence rises when people feel as if it is easy to get a job, even if it is not a high-paying one.
Job growth has slowed lately, averaging 182,000 a month under Trump vs. 220,000 a month in the 37 months at the end of Obama’s tenure. But the health of the labor market is evident, with the unemployment rate near half-century lows at 3.6 percent. The nation has added over 2 million jobs every year for the past nine years, an unprecedented streak of steady gains.
“Your chance of going to work tomorrow and getting laid off is lower than it’s ever been going back to 1948,” said Ian Shepherdson, chief economist at Pantheon Macroeconomics. “That feeling of job security is very important.”
DeHenau, 33, calls this the best economy of his working years. He voted for Obama and then Trump. He gives Obama credit for getting the upswing going, but he thinks the economy would not be as good as it now without Trump.
“I give Trump 80 to 90 percent of the credit,” DeHenau said. “Even under Obama when it was good, there was no profitability.”
There has been less praise for Trump in the manufacturing sector, which tumbled into a technical recession last year as the president’s trade war drove up prices and hurt purchases from other parts of the world.
Jamison Scott, who runs a small manufacturing company in Woodbridge, Connecticut, remembers the ugly surprise he got after Trump enacted steel tariffs in March 2018 and steel prices soared about 20 percent.
Scott, who manufactures and distributes air ducts and says he uses American steel, was worried how his company could manage the extra cost — or even keep getting enough steel. One steel shipment he ordered that year showed up with about a quarter less material than what he requested.
But steel prices have come back down in recent months, a welcome relief for Scott, and his business from throughout the country has picked up. Enough cash has been coming in that he bought a new plasma cutter and seam welder, the types of big purchases he had not made in years.
“Customers we haven’t heard from in a while are coming out of the woodwork,” said Scott, the executive vice president of Air Handling Systems. “The biggest difference for me is the volatility is gone.”
Manufacturing is now a smaller part of the overall U.S. economy, which is driven largely by the fast-growing service sector. Still, there are signs of a potential pickup, even for manufacturing. A popular manufacturing gauge, the Institute for Supply Management survey, recently reported its first expansionary reading since July.
There are two big question marks for the U.S. economy this year — how bad the impact of the coronavirus will be and whether business spending will pick up. Kudlow and many private-sector economists have predicted a small impact from the deadly coronavirus on the U.S. economy, shaving off about 0.2 percent from first-quarter growth. But it is yet another reason for leaders of large multinational companies to worry.
While consumers have continued spending at a healthy rate, business investment outside the housing sector contracted from April through December. Many leaders of large corporations do not hold the same economic ebullience that consumers and small-business owners do.
“When we look at the CEO confidence survey, it’s quite a different story,” said Lynn Franco, director of economic indicators and surveys at the Conference Board. “They are much more pessimistic. Trade has taken a toll on business investment.”
There are also concerns about the U.S. economy that Democratic presidential candidates have been talking up frequently, especially the lack of higher-paying jobs and the often burdensome costs of health care, child care and college.
Jobs that pay middle-class wages have been going away in recent years, replaced with really high-wage and really low-wage work. That trend is ongoing despite Trump’s repeated promises of a “blue-collar boom.”
“By and large, we are producing a lot of low-quality jobs,” said Mark Muro, director of the Metropolitan Policy Program at the Brookings Institution. “But a job is a job for a jittery nation.”
WASHINGTON — The White House proposed a $4.8 trillion election-year budget Monday that would slash major domestic and safety-net programs, setting up a stark contrast with President Donald Trump’s rivals as voting gets underway in the Democratic presidential primary.
The budget would pursue hundreds of billions of dollars in cuts to Medicaid and seek reductions in the Children’s Health Insurance Program while wringing some savings from Medicare despite Trump’s repeated promises to safeguard the program for older Americans.
The budget is a proposal to Congress, and lawmakers have mostly rejected the White House’s proposed cuts in the past. Still, the budget plan sets up the Trump administration’s policy priorities heading into the November elections and are likely to draw scrutiny in Washington and on the campaign trail. Trump has in the past not shown much interest in pursuing the budget cuts his aides have offered, and he didn’t make public comments about the plan on Monday.
Instead, one of his top advisers defended the proposed cuts, even as Democratic presidential candidates blasted the reductions.
Russell Vought, acting White House budget director, touted the proposed spending increases in the budget for NASA, immigration, opioid mitigation and veterans, while denying it would lead to benefit reductions for Medicare and Medicaid, as Democrats charged. Vought also said the budget includes widespread cuts to federal waste that would bring down the deficit.
“This continues to be a budget that funds priorities where the president supports spending money,” Vought told reporters. “We are trying to fund what his priorities are, what his campaign commitments are, and finding savings and inefficiencies where we possibly can.”
A central theme of the new budget is its attempt to scale back domestic programs. It would slash the Environmental Protection Agency budget by 26.5 percent over the next year, and cut the budget Department of Health and Human Services budget by 9 percent. The HHS includes the National Institutes of Health and the Centers for Disease Control and Prevention, which would see a budget cut even as it is under intense scrutiny over its response to the coronavirus. Officials said the part of the CDC that responds to emergencies such as the coronavirus would be protected.
“This is the future President Trump envisions for our nation,” said House Budget Committee Chairman John Yarmuth, D-Ky. “One where the federal government relinquishes any responsibility for the well-being of the American people in our nation. What the president has put forth is a destructive and irrational budget that intentionally goes after working families and vulnerable Americans.”
The plan would target the Education Department is for a nearly 8 percent cut, the Interior Department would be cut 13.4 percent, and the Housing and Urban Development department would be cut 15.2 percent. The State Department and U.S. Agency for International Development would be cut by 22 percent.
Trump has sought spending cuts in the past, only to back down immediately during negotiations with Democrats. For example, he has sought to cut numerous federal agencies multiple times and then reversed himself and approved budget increases. That’s because Trump has pushed for huge increases in military spending, and Democrats have said they would only go along with such a change if Trump backed more money for housing, education, and health care.
Trump did not defend any of the cuts in public. Over the weekend, he commented on the budget proposal briefly, noting on Twitter that he would not touch Social Security or Medicare.
But even some of Trump’s staunchest allies criticized his sharp cuts for domestic agencies, such as the Agriculture Department, which he is targeted for an 8 percent overall reduction. That was an indication that the budget will get a cold shoulder on Capitol Hill from the lawmakers of both parties who will be responsible for writing spending bills into law that will actually fund the government when the 2021 fiscal year begins Oct. 1.
Trump has made homelessness a key focus in the past year, but his budget would seek a big reduction in housing funds. He proposed an $8.6 billion cut for the Department of Housing and Urban Development for 2021, a 15.2 percent decrease from the amount enacted for 2020. The cuts, as in previous years, include eliminating the four-decade-old Community Development Block Grant program popular among congressional Democrats and Republicans as well as affordable housing grants to states and municipalities to help with the construction, purchase or rental of homes.
The block grants, funds that Congress has restored in past budgets, provides cities with money for affordable housing and other community needs, such as fighting blight, improving infrastructure and delivering food to homebound seniors. The administration, in its budget documents, said the program “has not demonstrated sufficient impact.”
Parts of the budget, however, show how the White House has shifted in the face of political blowback from past plans. It would preserve, for example, a handful of politically sensitive programs that in some cases have provoked uproars and caused Trump to backpedal when he’s tried to cut them in the past.
These include the Special Olympics and the Great Lakes Restoration Initiative — a program important to Michigan, Ohio, and Wisconsin, critical states for the 2020 election. Even as White House officials kept the Great Lakes fund steady, as it did for an ecosystem protection program in South Florida, similar programs in other, less politically important states are cut in the Trump budget.
Trump’s new budget calls for an increase in funding for the Department of Homeland Security, while keeping Pentagon spending mostly flat. The NASA budget would increase by 12 percent with new money aimed at putting U.S. astronauts back on the moon.
Even with all the other proposed spending cuts, the budget would not eliminate the federal deficit over the next 10 years, missing a longtime GOP fiscal target. Instead, White House officials said their budget proposal would close the deficit by 2035.
But it would only achieve this if the economy grows at an unprecedented, sustained 3 percent clip through 2025, levels the administration has failed to achieve for even one year so far. The U.S. economy grew 2.3 percent in 2019, the weakest level since Trump took office. Many economists believe economic growth will remain sluggish this year.
Because the government spends so much more money than it brings, the Treasury Department must borrow the difference by issuing debt. The debt has grown by roughly $3 trillion since Trump took office, and the budget plan would add more than $5 trillion to it over the next decade. There is currently more than $20 trillion in government debt, something Trump had vowed to eliminate by 2025 when running for office.
Trump’s budget aims to cut spending on safety-net programs such as Medicaid and food stamps, cutting food stamp spending by $181 billion over a decade. It proposes to squeeze hundreds of billions of dollars from Medicare over a decade through cost-saving proposals such as reforming medical liability and modifying payments to hospitals for uncompensated care.
Faced with a fundraising shortfall, Monadnock United Way announced Monday that it will cut its allocations to nonprofit agencies this year by $242,300.
That includes ending direct funding to many agencies after April 30. Meanwhile, the organization will continue funding a core set of programs — many of them multi-agency collaborations — as planned, or with small reductions.
Monadnock United Way President Liz LaRose called the organization’s decision a tough one.
“When you’re facing reductions in funding and reductions in what you’re able to give out, then it does force you to really focus and try to go deeper into something,” she said. That approach has a greater impact, she explained, than “doing a little bit for everyone.”
The focus going forward is on “highly targeted” initiatives related to the well-being of children and families, specifically in the areas of emergency housing and food access, early childhood success and family resources, according to a letter to members of the public announcing the change. (Sentinel president and COO Terrence L. Williams serves on the MUW board of directors.)
A Keene-based nonprofit organization, Monadnock United Way supports and partners with other area agencies to work on issues related to children, education and financial stability. It organizes an annual fundraising drive, which includes workplace giving campaigns and other individual donations.
MUW had hoped its campaign would hit $1,535,000 for 2020 — matching the prior year’s haul — but ended up with about $1.3 million, LaRose said.
The organization plans to put a total of $900,000 toward the Cheshire County Emergency Housing Collaborative, the Monadnock Food Pantries Collective, the Monadnock Home Visiting Alliance, the Monadnock Region Afterschool Collective and the Monadnock Parent Education Collective, six early childhood centers, a Southwestern Community Services program that provides preventive dental care to pregnant women and young children, and Impact Monadnock, MUW’s early childhood initiative.
LaRose said most of those groups are seeing a 5 percent reduction from their anticipated 2020 allotments.
Other organizations will see their 2020 awards slashed by two-thirds as they are “transitioned away from MUW funding,” the letter states. Some of those organizations also participate in the collectives that will continue to be funded.
The affected agencies were notified Monday, LaRose said.
Monadnock United Way is also reducing its staffing to the equivalent of six full-time positions, down from 8½. LaRose said one person is being let go. Two other jobs that are being eliminated, one full-time and one-part time, were already vacant.
The bulk of Monadnock United Way’s revenue comes from its annual fundraising drive.
A decade ago, the yearly campaign yielded more than $2 million, but has been pulling in less and less in recent years, LaRose said.
“We had hoped that we would hit a point where [the] campaign flattened out and then started to grow,” she said. But as it became clear that the latest campaign would show another decrease, she said, “that’s when we realized we were going to have to look at this as being more long-term.”
More details about MUW’s planned 2020 disbursements is available at muw.org/2020-investments.